health systems, monitoring, evaluation, learning.

Month: November 2012

as, you know, possibly from watching The Colbert Report, it’s dwali. as stephan and wikipedia note, diwali is the festival of lights or lamps.

being in india – or at least chennai – however, one might be hard-pressed to think that it was not the festival of sound (also, sweet pongal). firecrackers – or ‘crackers’ – play a large role. at all hours. regardless of any noise ordinances. regardless of whether my parents thought i was under assault when talking to me on the phone. seriously, if you know a war vet that still jumps at loud noises, please avoid indian cities during diwali. dr. dischord and the awful dynne would be so pleased.

so it was (ok, and because of a hard mattress) that i went out in search of sleeping pills. up till that point, i had not needed to actually purchase drugs in india. since part of my background is in private drug sellers, i was fairly confident i would be able to get something that would get me through the exploding nights of the rest of diwali. the private drug-retail market in india is fairly infamous for being unregulated – or, ‘the free-est market’ as (many) people thought was a funny joke. imagine my surprise, then, when at drug shop after drug shop, sellers heard my request, smiled sheepishly, asked for my presciption and, when i could not produce one, refused to sell the pills to me.

i finally found one shop at which the vendor, after looking around furtively, cut off some pills for a blister pack, stuck them in a little paper bag, and sent me off. i didn’t actually know what i had been given, so worked to reconstruct the letters visible on the back of the blister pack with my dad over the phone (no internet in chennai apt – this was 2007). i had some sort of anti-anxiety meds.

i tried asking around after that as to why my mission had been much more difficult than expected. the few non-‘i don’t know’ answers i got had nothing to do with fear of state regulation of pharmaceuticals but, rather, social censure. socially, people seemed to link sleeping pills, anti-depressents, and similar drugs with attempting to commit suicide. it was the community backlash from potentially being implicated in abetting a suicide attempt to which drug vendors were responding.

besides trying a few other times to buy sleeping pills and having difficulity, i haven’t researched this issue with any particular diligence. but, if true, it may suggest ways to work on getting drug vendors to behave appropriately, even if the formal regulatory system isn’t likely to catch up any time soon.

@altmandaniel pointed out that our position on what the Board should decide in the final post was not entirely clear. this is true – our goal was to lay out the positions and process rather than take a strong stance on the outcome. with regard to outcomes, the matching-based funding model would be the preferable option if you support facilitating private-sector delivery of drugs, while the integrated model represents a likely vote against intervention in the the private sector – at least absent a strong mandate for the TRP.

what @fanvictoria and i take a stand on is who and what needs to be considered by the Board. we further take a stand on the requisite transparency of the Board’s consideration.

this is a Big Moment for how evidence-based policy making plays out – and the decision at the end of the large-scale pilot period is neither as clear nor as technical as many people seem to have expected. both continuing AMFm and abruptly terminating it have strong implications for access to malaria drugs – but also in the political and policy spheres within implementing countries.

frankly, despite fast-paced and extensive evaluation efforts, what we learn about the AMFm is not really enough to say whether it is the ‘best’ approach to increasing access to malaria treatment. it is a reasonable proof-of-concept that the world does not fall apart when the private sector is used as a supply mechanism for increasing access to aid-subsidized drugs. beyond that, the debate remains both largely speculative and, in place of evidence about the relative impact on malaria morbidity and mortality, ideological.

given this, we step back in order to lay out the actual options and trade-offs that should be considered. some of these – how to improve dosing practices, how to encourage proper completion of doses by patients, how to strengthen in-country regulatory mechanisms and monitoring capacity, how to improve demand generation & information dissemination, how to include local pharmaceutical manufacturers – all often seem to be drowned out by either rancor over whether the private sector (in low and middle income countries) is an appropriate target for aid dollars or by discussions of specific types of subsidies and diagnostics. these are important moving parts in the bigger picture but they are not the only moving parts.

as a closing point on the Board’s decision, i‘d like to point out that many countries have already made a choice on whether it is right for ACTs to be sold in the private sector because they have given ACTs over-the-counter status. this is not a decision about where people do seek treatment for fever and whether that is the ‘right’ place. rather, the discussion should proceed from the positive reality that the private sector is utilized for fever treatment. thus, the needed normative and positive discussions are about

(a) whether it is ‘right’ for aid-subsidized drugs to be distributed in the private sector;

(b) whether people in low- and middle-income countries should pay for medicine at all;

(c) how aid money can be used most effectively to strengthen front-line worker and patient practices across sectors, including learning lessons from experiments with community health workers, nurses and pharmacists in the public sector, and drug shop staff in private sector; and, finally,

(d) how we can better design, test, evaluate, and cooperate on an approach or combination of approaches to reduce malaria morbidity and mortality that also strengthens systems for supplying treatment more generally.

Like this:

I made a very last-minute decision to go to Columbus, Ohio for the get-out-the-vote effort for the few days before the election and while I am still in a zombie-like, sleep-deprived and fast-food filled state, I am very glad I did. Our ‘turf’ was in Franklin County and we worked in predominantly African-American, low-income areas. There were far, far more foreclosures and vacant houses, deadbolts even on screendoors, and aggressive dogs (coupled with a far lesser amount of aggressive fencing) than I had imagined – in short, for a city that in my mind is OSU, it looked an awful like Detroit and Taylor, MI, where my Grandmolly used to live.

Our (vans of Harvard & MIT grad students) job in the two days leading up to the election and on “E Day” was to get to likely Obama supporters who were not as likely to actually make it out to vote. Most of the work of persuasion about who to vote for was abandoned by that point – save for a slight scripted plug for Obama’s auto industry intervention – so most of our knocking was on sympathetic, if misinformed, doors. The micro-targeting wasn’t perfect but it was pretty impressive. If I had to make one suggestion, it would be to do more with GPS so that the ‘walksheets’ could be ordered in a logical walking pattern. We all caught on pretty quickly but at least my first time out consisted of a lot of inefficiency and back-tracking. We had a script and a continuously rotating supply of literature to fasten, hang, or stick to doors of those not home. Our main goal was to make sure folks knew where and when to vote and what they needed to bring with them.

And, gracious, for the most targeted state in the Union, a lot of people did not know when and where to vote. On my first afternoon out – Sunday – very few people were actually at home but, finally, Savannah answered the door. She answered the door wrapped in a bed-sheet. She was pretty sure she would be able to vote at work. Over the course of the week, we met all kinds of people who thought they could vote up till Friday, had already voted at the pantry three weeks back, and so on. We also heard about robocalls that told them that if they had a parking ticket or something else on the record, they were not allowed to vote. In the end, there really wasn’t a replacement for the face-to-face conversation for information and encouragement.

They took good care of us at our staging location, which was in some sort of unoccupied office building with no heat and only one toilet for highly caffeinated and cold women. They had space heaters but between those, coffeemakers, powerstrips for charging phones, etc, we kept tripping the circuits and had to finally introduce an only-one-plug-per-wall rule. There was a lot of food, often homemade lasagna or casserole in big silver foil trays. One of the older African-American women helping organization the station carefully explained to me how she had made the casserole without meat – because, she had heard that there were some people who did not eat meat. Meanwhile, another woman made gluten-free cookies to bring in and the older African-American woman nearly fell out of her chair at the concept – ‘You mean cookies without flour?!?’

Our knocking schedule was one sweep by every house on our list on Sunday, encouraging early voting and providing Election Day info. Then, Monday, we did another sweep, focusing on Election Day. On Tuesday, we did three passes by all houses on our list, stopping only when we were convinced that had actually already voted, either by absentee ballot or early voting or simply earlier in the day. Some people were fairly shocked – is an, you guys have been here every day this week. “Yes, and we are going to keep coming back until you vote.” It wasn’t enough just for them to say they voted, we wanted to know where, how were the lines, where was their sticker. Fortunately, most people were fairly good natured, although several didn’t seem keen to open the door and instead just yelled through the window or from behind the door (including one genuine ‘who dat is?’ response to my knocking). And, there were some sad moments, as in ‘Is Michael home?’ ‘No.’ ‘Oh, will you see him today?’ ‘No, Michael’s been in jail for three years.’ Or “No, I haven’t seen Michael in weeks, I don’t know where he is.’

Oh. Well, if Michael comes home today, can you encourage him to vote? Here’s a leaflet.

As a side note, knocking on lots of doors – loudly and often repeatedly – hurts after a while and especially in the dry cold air. There were lots of paper cuts from the literature and bruised knuckles and experiments with alternative knocking techniques.

Anyway, our first evening out for dinner while we are still bedazzled and be-stickered with Obama gear, we were approached by a nice lady who was one of these rumored-to-exist undecided voters. It really came down to abortion; she was, by most of the rest of her positions, probably a textbook Obama supporter. She was staunchly Catholic; her just-ordained deacon husband waved from across the restaurant. I am not sure if she quite realized that she had stumbled onto a table of policy geeks and folks who had all recently read Friedman’s article on ‘why I am pro-life’ (also, commentary, here) and wielded similar arguments. The premise is that if you believe in the sanctity of life, you should be in it for the whole lifespan and should be generally against war and capital punishment and other ways of increasing constraints on healthy, happy, and long lives. It is a slam against the cognitive dissonance that must be maintained to care so desperately about life right up until it comes out of the mother’s body, at which point it can be ignored until it is potentially grandma facing a death panel. And, of the course, the cognitive dissonance in maintaining that the government’s hands should be kept off everything except things you don’t like. It is, overall, plea for consistency, coherence, and compassion in positions.

Our new friend was a very reasonable woman who is pro-life in all its senses – against capital punishment, against war – and just wanted to have a real talk about an issue that was important to her but had been turned into a polarized sound/image-byte-off. She told us about the floods of commercials and placards in town that showed – literally, graphically – abortion as fetus murder. She was able to laugh about the seeming absurdity of the image of all of us coming over from Boston/Cambridge with the intent of supporting or carrying out fetus-murder, as though that is what a ‘pro-choice’ crusader would do. We (it was about 8 to 1 in the conversation; she was a good sport) also raised issues about why abortion comes about and, therefore, how to prevent it. For one, we pointed out that sex education and access to contraceptives were pretty good ways of limiting the need for an abortion as a means of post-conception birth control. Two, we pointed out that abortions are likely to happen anyway and, in part, the issue is whether it happens safely or not. She was well-aware that the means existed with or without a law but taking the step of legalizing it was very difficult for her. Third, we talked about an issue that comes up very rarely in the conversation but one that obviously appealed to her – adoption. She pointed out that she knows many people who would help support a pregnant woman who was not getting the help she needed and were also willing to adopt children, even if they were, at she said, mentally disabled or HIV-positive. It is certainly true that the debate about alternatives to abortion has very much been shut-down in this country and that the adoption system does not facilitate these options and conversations.

In the end, we do not know how she voted, but we are pleased that we were able to give her the kind of even-toned, considered discussion she had been needing and was not getting in this overly exposed state – the nature of the campaign had sacrificed too much depth. We also gave her a chance to talk about something else that had happened: some Romney-Ryan supporters that had – just before they came to dinner – come to their church with a huge stack of pamphlets to hand out in church. Which is illegal and the couple said so. The R-R team said, OK, well, you can just put them on the windshields of your parishioners – a suggestion from which they also demurred. Finally, they tried to give the pamphlets into her 10-year-old daughter’s hands to take since her parents were not being compliant. It was in this frame of mind that she had approached us for a real conversation.

Another interesting character from our trip was a nice man that I will call ‘John’ – just in case. John had reached out to the Obama effort to offer his house as a place for people to stay. John had recently purchased farmland and a lovely, large house about 30 minutes outside Columbus and was willing to share. John himself had an interesting story besides being incredibly kind to give 15 people soft surfaces on which to crash (other parts of our team – on voter protection issues – were on the floor of a church and had no showers). John had worn many hats over the course of his life: the present one was a cowboy hat. He had gone to divinity school but decided not to become a preacher and instead talk Latin, religion, and American history at a Catholic high school. He then got started in IT entrepreneurship and, not so long ago, decided he hadn’t been a farmer yet. He was also just starting a catering company, specializing in chili. Just a few weeks before we arrived, had had been kicked in the chest by one of his horses and had a fractured sternum, though you wouldn’t have guessed it. John had been a lifelong Republican prior to the lead-up to the 2008 election. He was somewhat frustrated with Republican leadership and was interested in this guy whose life story seemed to parallel his own – his family was originally from Kansas but he grew up in Hawaii, where his father was stationed. This was enough to intrigue him and, though he doesn’t agree with everything Obama has done, he has stuck with him.

The final main character of our time in Columbus was a woman I will call Tisha. We heard about Tisha the first day we arrived at our ‘staging location’ (we were stationed at one main one but also helped at others when they had a high volunteer ‘flake rate’). On one of the previous rounds of knocking, Tisha had indicated that she would need a ride to the polls but we did not have her phone number and had never caught her at home since. One of the main coordinators (‘A’) at the staging location told us to keep an eye out for Tisha. We were trying to help facilitate rides, although we also heard that, interestingly, Somali cab drivers generally gave free rides to the polls on Election Day. We also heard of one case of a policeman taking an elderly lady and waiting the hour while she voted.

As it happened, my main buddy P, had Tisha on her turf list on the last day (the day of Three Knocks). We were in the same area – she had even addresses and I had odd. The last day gave you time to really get invested in these folks – if, on the first pass they said they were going to go later in the day, but they still hadn’t gone by the second pass, then you were pretty determined by the third one to get them out the door. But Tisha was not home on any of the three passes. Throughout the time week/end, P and I had been fairly creative with adding embellishments to the literature we were meant to leave at unanswered doors (I was also creative with the placement of the literature, which may or may not have been appreciated. We were not supposed to leave literature in mailboxes – quite a few of my pieces of literature were left sticking out of jack o’lanterns’ mouths, hopefully to the amusement of recipients.) We would add information on voting times and locations. I would add notes complimenting their Halloween decorations or the coolness of their names and so on. I woke up one woman around 11:00am. She promised she had set her alarm for 2:30 to go vote. I left a note saying I hoped she was well-rested and ready to vote. Anyway, on the last pass, Pamela left a note for Tisha that said that she knew she needed a ride and left A’s number on the last piece of literature. Tisha was our last stop – around 18:00 and the polls closed at 19:30 – and then we were shipped off to cover another turf. When we got back to the staging location at 20:00 or so, A happily announced that Tisha had called at about 19:00 and was whisked off to vote just in time.